CASE 15: VOICES COMMENT ON EVERYTHING I DO
History A 24-year-old man presents to hospital having got into a fight as he thought he was being watched and felt threatened. He appears to have fractured his thumb but is reluctant to let you examine him or order an X-ray. He looks suspicious and wary. When asked about his concerns he says that over the last few months he has been carefully monitored by government agencies. He has been hearing a voice out loud giving a running commentary on his thoughts and these are being broadcast to the government. Any machine enables the government to get inside his head and the voice is telling him it would be unwise to face the X-ray machine. The voice is not one that he recognizes, and it is sometimes derogatory, telling him he is stupid for giving his thoughts away for free. Initially the voice came and went but over the last few weeks it is present almost constantly and he cannot always sleep because even when he sleeps the voice comments on what he is thinking. He is exhausted. The man is absolutely convinced that the government is after him but he cannot explain why. There is no previous history and he denies any substance use. Until a few weeks ago he had been working as a kitchen assistant but was sacked for leaving jobs unfinished. There is no family history of any psychiatric illness.
Mental state examination
The man looks unkempt. He is wary and looks quite frightened and agitated. His eye contact is fleeting and he constantly looks around him in a perplexed manner. His speech is rambling and he does not express himself coherently. He occasionally uses words that you have not heard before and repeats them as though they have some significance. He does not come across as depressed. He has delusions of persecution. He has auditory hallucinations that provide a running commentary on every aspect of his behaviour. He has thought broadcast and thought withdrawal. He is orientated in person, but unclear about the time. He seems aware that he is in hospital but not quite sure why
Week (enter week #): (Enter assignment title)
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template
CC (chief complaint):
HPI:
Past Psychiatric History:
• General Statement:
• Caregivers (if applicable):
• Hospitalizations:
• Medication trials:
• Psychotherapy or Previous Psychiatric Diagnosis:
Substance Current Use and History:
Family Psychiatric/Substance Use History:
Psychosocial History:
Medical History:
• Current Medications:
• Allergies:
• Reproductive Hx:
ROS:
• GENERAL:
• HEENT:
• SKIN:
• CARDIOVASCULAR:
• RESPIRATORY:
• GASTROINTESTINAL:
• GENITOURINARY:
• NEUROLOGICAL:
• MUSCULOSKELETAL:
• HEMATOLOGIC:
• LYMPHATICS:
• ENDOCRINOLOGIC:
Physical exam: if applicable
Diagnostic results:
Assessment
Mental Status Examination:
Differential Diagnoses:
Reflections:
PRECEPTOR VERFICIATION:
I confirm the patient used for this assignment is a patient that was seen and managed by the student at their Meditrek approved clinical site during this quarter course of learning.
Preceptor signature: ________________________________________________________
Date: ________________________
References
_________________
Week 7: Psychiatric Evaluation of a 24-Year-Old Male with Delusions and Auditory Hallucinations
Student Name
College of Nursing-PMHNP, Walden University
PRAC 6635: Psychopathology and Diagnostic Reasoning
Faculty Name
Assignment Due Date
In this comprehensive psychiatric evaluation, we explore the case of a 24-year-old male who presents to the hospital with a chief complaint of having been involved in a fight, believing he was under surveillance and threatened. This case analysis delves into the patient’s history, mental state examination, and diagnostic reasoning, aiming to derive potential differential diagnoses and reflections on the clinical encounter.
Chief Complaint (CC)
The patient’s chief complaint centers on a perceived threat due to continuous monitoring by government agencies. He also reports hearing a voice that provides a running commentary on his thoughts and broadcasts them to the government. The voice discourages him from facing an X-ray machine and is often derogatory towards him.
History of Present Illness (HPI)
The patient describes experiencing government monitoring and auditory hallucinations over the last few months. Initially intermittent, the voice has become almost constant in recent weeks, significantly impacting his ability to sleep. The patient denies any substance use, and there is no family history of psychiatric illness. Until recently, he was employed as a kitchen assistant but was terminated for leaving tasks unfinished.
Mental State Examination (MSE)
The patient presents as unkempt, exhibiting signs of wariness, fear, and agitation. His eye contact is fleeting, and he displays constant perplexed glances. His speech is rambling and incoherent, occasionally using unfamiliar words with apparent significance. There is no evidence of depression. The MSE indicates delusions of persecution, auditory hallucinations, thought broadcasting, and thought withdrawal. While the patient is oriented to person, he appears unclear about the current time and his hospitalization purpose.
Diagnostic Reasoning and Differential Diagnoses
Based on the patient’s presentation, several potential diagnoses can be considered:
Schizophrenia: The presence of delusions, auditory hallucinations, and disorganized speech align with the diagnostic criteria for schizophrenia.
Brief Psychotic Disorder: Considering the relatively short duration of symptoms and the absence of previous psychiatric history, a brief psychotic disorder is a possibility.
Substance-Induced Psychosis: Although the patient denies substance use, this diagnosis should be carefully ruled out with additional investigations.
Delusional Disorder: Delusions of persecution without significant impairment in other areas of functioning might indicate a delusional disorder.
Other Psychotic Disorders: Other less common psychotic disorders should also be explored, such as schizoaffective disorder or schizophreniform disorder.
Reflections
This clinical encounter highlights the complexity of diagnosing and managing psychiatric conditions. The patient’s delusions and hallucinations significantly impact his daily life, leading to social and occupational impairment. As a mental health practitioner, it is crucial to approach such cases with empathy, understanding, and an evidence-based approach to diagnosis and treatment planning.
Conclusion
The comprehensive psychiatric evaluation of the 24-year-old male with delusions and auditory hallucinations underscores the need for a thorough assessment to derive accurate differential diagnoses. The patient’s condition requires careful monitoring and intervention to alleviate distress and improve functioning. As future mental health professionals, we must continue to hone our diagnostic reasoning skills and approach each patient encounter with expertise, compassion, and a commitment to providing optimal care.
References
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). American Psychiatric Publishing.
Brown, A. S. (2016). The environment and susceptibility to schizophrenia. Progress in Neurobiology, 142, 152-158.
Correll, C. U., & Auther, A. M. (2016). Research in people with psychosis risk syndrome: a review of the current evidence and future directions. Journal of Child Psychology and Psychiatry, 57(1), 87-105.
Fervaha, G., Zakzanis, K. K., & Foussias, G. (2016). Agid O. Motivational deficits in early schizophrenia: Prevalent, persistent, and key determinants of functional outcome. Schizophrenia Research, 166(1-3), 9-16.
